DOCSLIB.ORG

Evaluation and Treatment of Endometriosis

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Evaluation and Treatment of Endometriosis Evaluation and Treatment of Endometriosis SARINA SCHRAGER, MD, MS; JULIANNE FALLERONI, DO, MPH; and JENNIFER EDGOOSE, MD, MPH University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Endometriosis, which affects up to 10 percent of reproductive-aged women, is the presence of endometrial tissue outside of the uterine cavity. It is more common in women with pelvic pain or infertility (70 to 90 percent and 21 to 40 percent, respectively). Some women with endometriosis are asymptomatic, whereas others present with symptoms such as debilitating pelvic pain, dysmenorrhea, dyspareunia, and decreased fertility. Diagnosis of endometriosis in primary care is predominantly clinical. Initial treatment includes common agents used for primary dysmenorrhea, such as nonsteroidal anti-inflammatory drugs, combination estrogen/progestin contraceptives, or progestin-only contraceptives. There is some evidence that these agents are helpful and have few adverse effects. Referral to a gynecol- ogist is necessary if symptoms persist or the patient is unable to become pregnant. Laparoscopy is commonly used to confirm the diagnosis before additional treatments are pursued. Further treatments include gonadotropin-releasing hormone analogues, danazol, or surgical removal of ectopic endometrial tissue. These interventions may control symptoms more effectively than initial treatments, but they can have significant adverse effects and limits on dura- tion of therapy. (Am Fam Physician. 2013;87(2):107-113. Copyright © 2013 American Academy of Family Physicians.) ▲ Patient information: ndometriosis is defined as the by the fact that the most commonly affected A handout on this topic is presence of endometrial glandu- sites are closest to the fallopian tubes.6 In available at http://familydoctor.org/ lar and/or stromal cells outside of addition, endometriosis often occurs in online/famdocen/home/ the uterine cavity. There are gen- women with outflow obstruction, such as women/reproductive/ Eerally three distinct clinical presentations: cervical stenosis, a transverse vaginal sep- gynecologic/476.html. endometrial implantation superficially on tum, and an imperforate hymen.7 the peritoneum; endometrial lined ovarian Although women with endometriosis have cysts (chocolate cysts) or endometriomas; higher volumes of refluxed menstrual blood and endometriotic nodules (a complex, solid and endometrial tissue,8 most women have mass of endometrial, adipose, and fibro- some component of retrograde menstrua- muscular tissue found between the rectum tion. The plasminogen activator inhibitor and vagina).1 However, further laparoscopic gene has been shown to increase the likeli- studies of the peritoneum also have shown hood of endometrial implantation after ret- nonclassic lesions, such as clear vesicles, red rograde menstruation.6 vesicles, or microscopic disease.2 Typically, The coelomic metaplasia theory of endo- ectopic endometrial tissue is found within metriosis proposes that the coelomic epi- the pelvis (Table 1).3 Although reported thelium of the peritoneal cavity retains in virtually all organ systems, extrapelvic deposition is exceedingly rare. Endometriosis is generally considered Table 1. Common Sites of a benign disease. However, several large Endometriosis cohort studies suggest that endometrio- sis is an independent risk factor for clear- Percentage cell carcinoma and endometrioid ovarian Site of patients 4 carcinoma. Ovaries 55 Anterior cul-de-sac 35 Etiology Posterior broad ligaments 35 The earliest and most widely accepted the- Posterior cul-de-sac 34 ory of endometriosis etiology is that refluxed Uterosacral ligaments 28 menstrual tissue enters the pelvic perito- neal cavity and embeds into other intra- Information from reference 3. abdominal areas.5,6 This theory is supported DownloadedJanuary 15, from 2013 the ◆ American Volume Family87, Number Physician 2 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2013 American Academy of FamilyAmerican Physicians. Family For the Physicianprivate, non -107 commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Endometriosis SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Transvaginal ultrasonography is the preferred imaging modality for C 26 women with suspected endometriosis. Ovulation suppression therapies, such as oral contraceptives and A 26, 32, 36 gonadotropin-releasing hormone analogues, are effective for treating endometriosis pain. Surgical treatment of endometriosis improves pregnancy rates. A 26, 47 Ovulation suppression therapies do not improve pregnancy rates A 45 in patients with endometriosis. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml. multipotential cells that can develop into the condition, with an average of 17.8 days endometriotic tissue. This explains rare spent in bed.17 cases of endometriosis in prepubertal girls, women with Müllerian agenesis, and men.6 Risk Factors Another theory is that endometrial tis- It has been reported that the risk of endome- sue can be transported to distant sites via triosis is six times higher in first-degree rela- lymphatic and vascular channels, which tives of women with severe endometriosis.9 explains rare cases of extra-abdominal However, a more recent case-control study endometriosis.6 Finally, newer research sug- showed that the familial impact on the inci- gests an immunologic component to the dence of endometriosis is not significant.18 development of endometriosis. Concentra- Early menarche and late menopause, tions of macrophages, leptin, tumor necro- which lead to increased exposure to men- sis factor-α, and interleukin-6 often are struation, are commonly cited risk factors higher in the abdominal fluid of women for endometriosis.5,19 However, epidemio- with endometriosis.6,9,10 logic studies are equivocal as to whether these are true risk factors or findings asso- Epidemiology ciated with the disease itself.20 Low body Endometriosis is an estrogen-dependent dis- mass index21,22 and higher caffeine or alco- ease predominantly affecting reproductive- hol consumption21 also are associated with aged women, with the highest incidence an increased risk of endometriosis. Table 2 among women 25 to 29 years of age.11 The includes possible risk factors for the prevalence of endometriosis in the general population is difficult to accurately assess because some women with the disease Table 2. Risk Factors for have limited or no symptoms. Some stud- Endometriosis ies suggest that it affects up to 10 percent of 12 reproductive-aged women. Endometriosis Early menarche is diagnosed in 21 to 40 percent of women First-degree relative with endometriosis 13 with infertility and in 70 to 90 percent of Late menopause 14 women with chronic pelvic pain. Low body mass index In the United States, endometriosis is Müllerian anomalies the third leading cause of gynecologic hos- Nulliparity 15 pitalizations. It is estimated that the dis- Prolonged menstruation (> five days) ease leads to $2,801 in health care costs Shorter lactation intervals and $1,023 in lost productivity at work Shorter menstrual cycles (< 28 days) 16 per patient annually. In one nationwide White race (compared with black race) survey, 50 percent of women with endo- metriosis reported spending entire days in Information from references 20 through 22. bed over the previous 12 months because of 108 American Family Physician www.aafp.org/afp Volume 87, Number 2 ◆ January 15, 2013 Endometriosis Table 3. Symptoms and Comorbidities Associated with Higher Rates of Endometriosis Odds ratio Diagnosis (95% confidence The diagnosis of endometriosis in primary Symptoms/comorbidities interval) care is initially clinical and based on history Infertility/subfertility 8.2 (6.9 to 9.9) and physical examination findings. Histologic Dysmenorrhea 8.1 (7.2 to 9.3) confirmation is usually achieved with the Ovarian cysts 7.3 (5.7 to 9.4) detection of extrauterine endometrial cells on Dyspareunia and/or 6.8 (5.7 to 8.2) laparoscopy. Less invasive diagnostic tests are postcoital bleeding being pursued. Transvaginal ultrasonogra- Abdominal or pelvic pain 5.2 (4.7 to 5.7) phy can reliably detect cystic endometriomas Pelvic inflammatory 3.0 (2.5 to 3.6) (89 percent sensitivity, 91 percent specific- disease ity) and is considered the imaging modality Irritable bowel syndrome 1.6 (1.3 to 1.8) of choice,26,27 although the test does not reli- ably detect smaller endometrial implants. The Information from reference 23. cancer antigen 125 assay has been extensively researched, but a large systematic review of 23 studies shows limited overall value in disease.20-22 Oral contraceptives and regu- the diagnosis of endometriosis. The cancer lar exercise (i.e., more than four hours per antigen 125 level is often elevated in women week) may decrease the risk.5,21 with endometriosis, but its specificity for the disease is low.28 Magnetic resonance imag- Clinical Presentation ing also is being explored, particularly for The clinical presentation of endometriosis is deeper rectosigmoid and ureteral infiltrating highly variable and ranges from debilitating lesions, but it is not a standard diagnostic tool pelvic
Load more

Recommended publications
  • Localised Provoked Vestibulodynia (Vulvodynia): Assessment and Management
    FOCUS Localised provoked vestibulodynia (vulvodynia): assessment and management Helen Henzell, Karen Berzins Background hronic vulvar pain (pain lasting more than 3–6 months, but often years) is common. It is estimated to affect 4–8% of Vulvodynia is a chronic vulvar pain condition. Localised C women at any one time and 10–20% in their lifetime.1–3 provoked vestibulodynia (LPV) is the most common subset Little attention has been paid to the teaching of this condition of vulvodynia, the hallmark symptom being pain on vaginal so medical practitioners may not recognise the symptoms, and penetration. Young women are predominantly affected. LPV diagnosis is often delayed.2 Community awareness is low, but is a hidden condition that often results in distress and shame, increasing with media attention. Women can be confused by the is frequently unrecognised, and women usually see a number symptoms and not know how to discuss vulvar pain. The onus is of health professionals before being diagnosed, which adds to on medical practitioners to enquire about vulvar pain, particularly their distress and confusion. pain with sex, when taking a sexual or reproductive health history. Objective Vulvodynia The aim of this article is to inform health providers about the Vulvodynia is defined by the International Society for the Study assessment and management of LPV. of Vulvovaginal Disease (ISSVD) as ‘chronic vulvar discomfort, most often described as burning pain, occurring in the absence Discussion of relevant findings or a specific, clinically identifiable, neurologic 4 Diagnosis is based on history. Examination is used to support disorder’. It is diagnosed when other causes of vulvar pain have the diagnosis.
    [Show full text]
  • Impact of a Multidisciplinary Vulvodynia Program on Sexual Functioning and Dyspareunia
    238 Impact of a Multidisciplinary Vulvodynia Program on Sexual Functioning and Dyspareunia Lori A. Brotto, PhD, Paul Yong, MD, Kelly B. Smith, PhD, and Leslie A. Sadownik, MD Department of Gynaecology, University of British Columbia, Vancouver, BC, Canada DOI: 10.1111/jsm.12718 ABSTRACT Introduction. For many years, multidisciplinary approaches, which integrate psychological, physical, and medical treatments, have been shown to be effective for the treatment of chronic pain. To date, there has been anecdotal support, but little empirical data, to justify the application of this multidisciplinary approach toward the treatment of chronic sexual pain secondary to provoked vestibulodynia (PVD). Aim. This study aimed to evaluate a 10-week hospital-based treatment (multidisciplinary vulvodynia program [MVP]) integrating psychological skills training, pelvic floor physiotherapy, and medical management on the primary outcomes of dyspareunia and sexual functioning, including distress. Method. A total of 132 women with a diagnosis of PVD provided baseline data and agreed to participate in the MVP. Of this group, n = 116 (mean age 28.4 years, standard deviation 7.1) provided complete data at the post-MVP assessment, and 84 women had complete data through to the 3- to 4-month follow-up period. Results. There were high levels of avoidance of intimacy (38.1%) and activities that elicited sexual arousal (40.7%), with many women (50.4%) choosing to focus on their partner’s sexual arousal and satisfaction at baseline. With treatment, over half the sample (53.8%) reported significant improvements in dyspareunia. Following the MVP, there were strong significant effects for the reduction in dyspareunia (P = 0.001) and sex-related distress (P < 0.001), and improvements in sexual arousal (P < 0.001) and overall sexual functioning (P = 0.001).
    [Show full text]
  • Progestin-Based Contraceptive on the Same
    PROGESTIN-BASED CONTRACEPTIVE ON THE SAME DAY AS MEDICAL ABORTION Jeanna Park, MD1, Nuriya Robinson, MD1, Ursula Wessels, MD2, James Turner, MD2, Stacie Geller, PhD1 1Department of Obstetrics and Gynecology, University of Illinois, Chicago, USA 2Department of Obstetrics and Gynecology, Lower Umfolozi District War Memorial Hospital, Empangeni, South Africa INTRODUCTION AND OBJECTIVES METHODS • Major cause of maternal mortality in South Africa = unsafe abortion Retrospective chart review in KwaZulu Natal, South Africa - Lower • New focus on family planning – providing immediate contraception with Umfolozi District War Memorial Hospital and Eshowe Hospital. etonogestrel implant or depot medroxyprogesterone acetate (DMPA) injection at the same time as medical abortion Inclusion criteria: • Historically, contraception offered at second follow-up visit after medical • Pregnant women aged 15-49 abortion complete – but many women lost to follow-up and never receive • Gestational age ≤ 63 days by ultrasound contraception (3) • Underwent medical abortion between August 2013 and July 2014 • Studies support when contraception is given at time of abortion, • Followed medical abortion protocol with oral mifepristone continuation rates high (4) and repeat abortion rates low (5) 200mg followed by sublingual misoprostol 800mcg 24 hours later • Theoretical risk - providing a progestin-based contraceptive (i.e. • Received either the etonogestrel implant or DMPA injection for etonogestrel or DMPA) at time of medical abortion may interfere with contraception
    [Show full text]
  • Pharmacology/Therapeutics II Block III Lectures 2013-14
    Pharmacology/Therapeutics II Block III Lectures 2013‐14 66. Hypothalamic/pituitary Hormones ‐ Rana 67. Estrogens and Progesterone I ‐ Rana 68. Estrogens and Progesterone II ‐ Rana 69. Androgens ‐ Rana 70. Thyroid/Anti‐Thyroid Drugs – Patel 71. Calcium Metabolism – Patel 72. Adrenocorticosterioids and Antagonists – Clipstone 73. Diabetes Drugs I – Clipstone 74. Diabetes Drugs II ‐ Clipstone Pharmacology & Therapeutics Neuroendocrine Pharmacology: Hypothalamic and Pituitary Hormones, March 20, 2014 Lecture Ajay Rana, Ph.D. Neuroendocrine Pharmacology: Hypothalamic and Pituitary Hormones Date: Thursday, March 20, 2014-8:30 AM Reading Assignment: Katzung, Chapter 37 Key Concepts and Learning Objectives To review the physiology of neuroendocrine regulation To discuss the use neuroendocrine agents for the treatment of representative neuroendocrine disorders: growth hormone deficiency/excess, infertility, hyperprolactinemia Drugs discussed Growth Hormone Deficiency: . Recombinant hGH . Synthetic GHRH, Recombinant IGF-1 Growth Hormone Excess: . Somatostatin analogue . GH receptor antagonist . Dopamine receptor agonist Infertility and other endocrine related disorders: . Human menopausal and recombinant gonadotropins . GnRH agonists as activators . GnRH agonists as inhibitors . GnRH receptor antagonists Hyperprolactinemia: . Dopamine receptor agonists 1 Pharmacology & Therapeutics Neuroendocrine Pharmacology: Hypothalamic and Pituitary Hormones, March 20, 2014 Lecture Ajay Rana, Ph.D. 1. Overview of Neuroendocrine Systems The neuroendocrine
    [Show full text]
  • Women's Health Concerns
    WOMEN’S HEALTH Natalie Blagowidow. M.D. CONCERNS Gynecologic Issues and Ehlers- Danlos Syndrome/Hypermobility • EDS is associated with a higher frequency of some common gynecologic problems. • EDS is associated with some rare gynecologic disorders. • Pubertal maturation can worsen symptoms associated with EDS. Gynecologic Issues and Ehlers Danlos Syndrome/Hypermobility •Menstruation •Menorrhagia •Dysmenorrhea •Abnormal menstrual cycle •Dyspareunia •Vulvar Disorders •Pelvic Organ Prolapse Puberty and EDS • Symptoms of EDS can become worse with puberty, or can begin at puberty • Hugon-Rodin 2016 series of 386 women with hypermobile type EDS. • 52% who had prepubertal EDS symptoms (chronic pain, fatigue) became worse with puberty. • 17% developed symptoms of EDS with puberty Hormones and EDS • Conflicting data on effects of hormones on connective tissue, joint laxity, and tendons • Estriol decreases the formation of collagen in tendons following exercise • Joint laxity increases during pregnancy • Studies (Non EDS) • Heitz: Increased ACL laxity in luteal phase • Park: Increased knee laxity during ovulation in some, but no difference in hormone levels among all (N=26) Menstrual Cycle Hormonal Changes GYN Issues EDS/HDS:Menorrhagia • Menorrhagia – heavy menstrual bleeding 33-75%, worst in vEDS • Weakness in capillaries and perivascular connective tissue • Abnormal interaction between Von Willebrand factor, platelets and collagen Menstrual cycle : Endometrium HORMONAL CONTRACEPTIVE OPTIONS GYN Menorrhagia: Hormonal Treatment • Oral Contraceptive Pill • Progesterone only medication • Progesterone pill: Norethindrone • Progesterone long acting injection: Depo Provera • Long Acting Implant: Etonorgestrel • IUD with progesterone Hormonal treatment for Menorrhagia •Hernandez and Dietrich, EDS adolescent population in menorrhagia clinic •9/26 fine with first line hormonal medication, often progesterone only pill •15/26 required 2 or more different medications until found effective one.
    [Show full text]
  • The Older Woman with Vulvar Itching and Burning Disclosures Old Adage
    Disclosures The Older Woman with Vulvar Mark Spitzer, MD Itching and Burning Merck: Advisory Board, Speakers Bureau Mark Spitzer, MD QiagenQiagen:: Speakers Bureau Medical Director SABK: Stock ownership Center for Colposcopy Elsevier: Book Editor Lake Success, NY Old Adage Does this story sound familiar? A 62 year old woman complaining of vulvovaginal itching and without a discharge self treatstreats with OTC miconazole.miconazole. If the only tool in your tool Two weeks later the itching has improved slightly but now chest is a hammer, pretty she is burning. She sees her doctor who records in the chart that she is soon everyyggthing begins to complaining of itching/burning and tells her that she has a look like a nail. yeast infection and gives her teraconazole cream. The cream is cooling while she is using it but the burning persists If the only diagnoses you are aware of She calls her doctor but speaks only to the receptionist. She that cause vulvar symptoms are Candida, tells the receptionist that her yeast infection is not better yet. The doctor (who is busy), never gets on the phone but Trichomonas, BV and atrophy those are instructs the receptionist to call in another prescription for teraconazole but also for thrthreeee doses of oral fluconazole the only diagnoses you will make. and to tell the patient that it is a tough infection. A month later the patient is still not feeling well. She is using cold compresses on her vulva to help her sleep at night. She makes an appointment. The doctor tests for BV.
    [Show full text]
  • Long Term Follow-Up of Etonogestrel and Levonorgestrel Contraceptive
    October 6, 2015. RHSC, Oslo Long term follow-up of one-rod etonogestrel (ENG) and two-rod levonorgestrel (LNG) contraceptive implants: comparing effectiveness, continuation rates and adverse effects Moazzam Ali MBBS, PhD, MPH , for the WHO Study Group on Contraceptive Implants for Women Department of Reproductive Health and Research 1 Presentation outline Background Objectives of the study Methodology Description of population enrolled Key findings on effectiveness, adverse events and method continuation 2 Filename WHO Consultation on Implantable Contraceptives for Women 2001 Review on safety and effectiveness of available implantable contraceptives for women. Published in an issue of Contraception 65 (1) 2002. Levonorgestrel and etonogestrel implants are highly effective and safe (annual pregnancy rates in the order of 0.0-0.5 per 100 women) . No comparative trial of Jadelle and Implanon had been done . Lack of reliable data on common non-serious side effects typically attributed to progestins . Consideration to extend the trial up to 5 years if justified by initial data. 3 SecondNorplant generation (6 capsules) contraceptive implantsJadelle (2 rods) One-rod Etonogestrel Two-rod Levonorgestrel Approved duration of use: 3 yrs Approved duration of use: 5 yrs. EVA copolymer rod Silastic medical covered by a thin adhesive EVA membrane Silastic tubing 68 mg ENG 43 mm 40 mm 75 mg LNG embedded in crystals EVA copolymer in silicone copolymer 2.4 mm 2.0 mm 4 Rationale for study extension at end of year 3 Few pregnancies reported for the etonogestrel implant during 3 years of use Pharmacokinetic data indicated ENG implant likely to be effective for contraception beyond 3 years of use Huber J.
    [Show full text]
  • Vulvodynia: What We Know and Where We Should Be Going
    SYSTEMATIC REVIEW,META-ANALYSIS,NARRATIVE REVIEW Vulvodynia: What We Know and Where We Should Be Going Logan M. Havemann, BA,1 David R. Cool, PhD,1,2 Pascal Gagneux, PhD,3 Michael P.Markey, PhD,4 Jerome L. Yaklic, MD, MBA,1 Rose A. Maxwell, PhD, MBA,1 Ashvin Iyer, MS,2 and Steven R. Lindheim, MD, MMM1 evolving definitions, and unidentified pathogenesis of disease. Objective: The aim of the study was to review the current nomenclature The pathogenesis of VVD remains largely unknown and is likely and literature examining microbiome cytokine, genomic, proteomic, and multifactorial. Recent research has focused largely on an inflam- glycomic molecular biomarkers in identifying markers related to the under- matory pathogenesis, and our current understanding suggests an standing of the pathophysiology and diagnosis of vulvodynia (VVD). initial vaginal insult with infection1 followed by an inflammatory Materials and Methods: Computerized searches of MEDLINE and response10 that may result in peripheral and central pain sensitiza- PubMed were conducted focused on terminology, classification, and tion, mucosal nerve fiber proliferation, hypertrophy, hyperplasia, “ ” omics variations of VVD. Specific MESH terms used were VVD, and enhanced systemic pain perception.11 With advancements in vestibulodynia, metagenomics, vaginal fungi, cytokines, gene, protein, in- our ability to measure transcriptomic markers of disease, as well flammation, glycomic, proteomic, secretomic, and genomic from 2001 to as the progress in mapping the human genome and how variations 2016. Using combined VVD and vestibulodynia MESH terms, 7 refer- affect disease states, new avenues of research in the pathogenesis ences were identified related to vaginal fungi, 15 to cytokines, 18 to gene, of VVD can now be explored including the potential role for 43 to protein, 38 to inflammation, and 2 to genomic.
    [Show full text]
  • Reproductive Experiences Among Women with Vulvodynia Nora S
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Springer - Publisher Connector Johnson et al. BMC Pregnancy and Childbirth (2015) 15:114 DOI 10.1186/s12884-015-0544-x RESEARCH ARTICLE Open Access “You have to go through it and have your children”: reproductive experiences among women with vulvodynia Nora S. Johnson, Eileen M. Harwood and Ruby H.N. Nguyen* Abstract Background: Vulvodynia is a potentially debilitating chronic pain condition affecting the vulva (external genitalia) in women, with typical age of onset during the early-to mid-reproductive years. Yet, virtually nothing is known about the thoughts, feelings and experience of vulvodynia patients regarding conception, pregnancy and delivery; including the effect that a hallmark symptom, dyspareunia (painful sex), can have on a couple’s physical and emotional ability to conceive. We sought to describe these experiences and beliefs among women with vulvodynia who were pregnant or who recently had delivered a child. Methods: The study used in-depth, qualitative exploratory interview methods to gain a deeper understanding of these experiences for 18 women with vulvar pain who were recruited from an existing, nationally-sampled prospective pregnancy cohort study. Results: Four major themes were reported by our participants. Women described their reaction to pain as volatile at first, and, over time, more self-controlled, regardless of medical treatment; once the volatility became more stable and overall severity lessened, many women began planning for pregnancy. Techniques described by women to cope with pain around pregnancy included pain minimization, planning pregnancy-safe treatment and timing intercourse around ovulation.
    [Show full text]
  • Implanon®) in Common Marmosets (Callithrix Jacchus)
    animals Article Retrospective Analysis of the Effectiveness and Reversibility of Long-Acting Contraception Etonogestrel (Implanon®) in Common Marmosets (Callithrix jacchus) Sandra Roubos 1, Annet L. Louwerse 1, Jan A.M. Langermans 1,2 and Jaco Bakker 1,* 1 Animal Science Department, Biomedical Primate Research Centre, Lange Kleiweg 161, 2288GJ Rijswijk, The Netherlands; [email protected] (S.R.); [email protected] (A.L.L.); [email protected] (J.A.M.L.) 2 Department Population Health Sciences, Animals in Science and Society, Faculty of Veterinary Medicine, Utrecht University, 3584 CM Utrecht, The Netherlands * Correspondence: [email protected]; Tel.: +31-152-842-579 Simple Summary: Due to the breeding success of common marmosets in captivity, colony managers need to achieve a balance between maintaining sustainable population numbers while preventing the breeding of surplus animals. Population control can be achieved by various methods, reversible and nonreversible. Long-acting reversible contraceptives are preferred, as they are not permanent and eliminate the logistical problems associated with the daily or weekly administration of oral or ® injectable contraceptives. Implanon (etonogestrel) is a widely used progestin-based contraceptive in marmosets with the theoretical advantages of being reversible and long-acting. However, no dose Citation: Roubos, S.; Louwerse, A.L.; and efficacy data are available yet. In this study, we examined, by using electronic health records, Langermans, J.A.M.; Bakker, J. the relationship between the use of one-fourth or one-third of an etonogestrel implant in female Retrospective Analysis of the marmosets and the number of parturitions, interbirth interval, litter size, body weight, stillbirths and Effectiveness and Reversibility of unintended pregnancies.
    [Show full text]
  • Vulvodynia: a Self-Help Guide
    Vulvodynia: A Self-Help Guide www.nva.org Table of Contents Introduction Introduction ..................................................................................... 1 Welcome to the NVA’s self-help guide for women with vulvodynia. We Section I: Learning the Basics ....................................................... 2 created this guide to answer many of your questions about vulvodynia and Gynecological Anatomy its treatment, and to offer suggestions for improving your quality of life. First Normal and Abnormal Vulvovaginal Symptoms we’d like to highlight a few important points. Vulvar Self-Examination Each woman’s experience with vulvodynia is unique, with symptoms ranging Section II: Understanding Vulvodynia ........................................... 9 from mild to incapacitating. If your pain level is mild, some of the information What is Vulvodynia? in this guide may not apply to you. What Causes Vulvodynia? How is Vulvodynia Diagnosed? Some doctors are still unfamiliar with vulvodynia. Many women spend a long Co-Existing Conditions time wondering what is wrong with them and see several doctors before How is Vulvodynia Treated? they are told they have vulvodynia. An accurate diagnosis is half the battle, Self-Help Strategies for Vulvar Pain so now you can focus your efforts on finding helpful treatments and feeling better. Section III: Understanding Chronic Pain ..................................... 17 How We Feel Pain When you start a new treatment, try to be patient and hopeful. There are When Pain Becomes Chronic many treatment options for vulvodynia and no single treatment works equally Coping with Chronic Pain well for all women. Sometimes progress is slow and you may only notice improvement on a monthly, rather than daily, basis. Section IV: Quality of Life Issues ................................................. 20 Overcoming Challenges in Your Intimate Relationship It is important to participate in treatment decisions and discuss your progress Keeping Sexual Intimacy Alive (or lack of it) with your doctor or other health care provider.
    [Show full text]
  • World Health Organization Model List of Essential Medicines, 21St List, 2019
    World Health Organizatio n Model List of Essential Medicines 21st List 2019 World Health Organizatio n Model List of Essential Medicines 21st List 2019 WHO/MVP/EMP/IAU/2019.06 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. World Health Organization Model List of Essential Medicines, 21st List, 2019. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.
    [Show full text]